Beyond equity: Swedish health policy and the private sector

The rapid development of private medicine in Sweden poses a challenge to that nation's traditional commitment to equity and a public system of health care. Economic constraints in public-sector spending, physician intent in private practice, popular interest in individual choice, and criticism of the public system have been the stimulus. The dominant Social Democrats will likely accept those elements of the private sector that are ideologically compatible, but resist others.     

Public policy and private sector provision of health services

Public sector policies often try to extend access and redirect public resources, depending on private sector actions. These strategies focus on reducing demand, improving efficiency, and generating increased revenues in the public sector. In order to provide incentives for efficiency, acquire capital, and redirect limited public resources to public priorities, there must be an expanded role for the private market in the provision of health services. This presents opportunities to improve the focus of resources on high-priority health activities in the public sector and to make more effective and efficient use of the resources of the private sector. The authors discuss the form that such policies may take. However, while the overall set of options available to policy makers can be identified, what is an effective strategy in one country may be neither appropriate nor feasible in another. The challenge to policy research is not to identify what works, but rather to understand the conditions that make a policy effective in some settings but not in others. The objective is not to prescribe the actions to take but to understand the factors that create the current experience in a specific setting.     

Reforming the Swedish health services: the international context

This article reviews the performance of Swedish health services in the international context. It notes that Sweden stands out as a country which has made a major commitment to the welfare state. Nowhere is this more evident than in the health services. Expenditure on health care is high by international standards and over 90% of expenditure derives from public sources. Despite Sweden's achievement in providing comprehensive health care to its population, a number of problems have emerged in recent years. In response to these problems, there has been a debate about options for reform. It is suggested that management reforms may offer the best way forward in improving the performance of health services. Policy makers should take advantage of the decentralised nature of the Swedish system to initiate and evaluate different reforms in different county councils.     

Health sector reform: making health development sustainable

Health sector reform is underway or under consideration.in countries throughout the world and at all levels of income. This paper presents an overview of key concepts and approaches to health sector reform in developing countries. Reform implies sustained, purposeful, and fundamental changes in the health sector. While it is difficult to define precisely what constitutes a true reform, there is widespread consensus that reform is a process of change involving the what, who, and how of health sector action. Health is increasingly included as an important goal of national development. It can make development more sustainable. The paper outlines some general and specific health sector reform strategies that can contribute to sustainable development for countries at all levels of income, although the strategies will differ in content and emphasis. Health sector reform should be based on an holistic view of the health sector. The paper presents two frameworks to aid in reform design: one highlighting the linkages between different institutional actors in the health sector; the second addressing linkages across different functional areas of reform action. In order to develop and carry out reform, information and analysis is needed. A variety of practical tools now available for this purpose are discussed, encompassing all the different areas of action. While tool development should continue, reform proponents already have much to work with. Given global interest, the importance of health sector reform in development strategies, and significant existing knowledge and experience, country level analysis and action should proceed vigorously.     

Widening the debate? Consultation and participation in local health care planning in the English and Swedish health services.

In both English and Swedish health care, there is currently much interest in encouraging public consultation and participation in public service planning in order to improve quality, enhance local accountability, and help to inform and legitimize difficult decisions about health care priorities. This article explores the progress of local budget holders for health services in the two countries--primary care groups/trusts in England and county councils and municipalities in Sweden--in developing consultative and participative processes. Using secondary and primary research methods, the study identified much activity among English primary care groups/trusts, although with less certainty of outcome. In Sweden, initiatives were limited to a few county councils, were more distinctive, and in the case of one county council, resulted in the sustained channeling of citizens' views. In comparing and contrasting the approaches in the two countries, the authors note the importance of political cultures and institutional arrangements as well as, more generally, the complexities and challenges of consultation and participation in health care planning.     

Private sector health services use in the Omsk region

The progress made by the private medical sector in different Russia's regions has been uneven. A key share of private medical facilities is concentrated in big cities. The frequency rate of citizens' asking the rural and urban private practitioners for medical care was investigated by the example of the Omsk Region. The dynamic morbidity and the specificity of its structure are described on the basis of the data contained in basic medical registration documents borrowed from private medical institutions. The importance and value of the information-and-analytical cooperation between the private-sector structures, on the one hand, and the healthcare management bodies, on the other hand, are pointed out.     

Reforming the health sector in Thailand: the role of policy actors on the policy stage

This paper reports on exploratory research carried out into the processes of policy-making, and in particular health sector reform, in the health sector of Thailand. It is one of a set of studies examining health sector reform processes in a number of countries. Though in the period under study (1970-1996) there had been no single health sector reform package in Thailand, there was interest in a number of quarters in the development of such an initiative. It is clear, however, that despite recognition of the need for reform such a policy was far from being formulated, let alone implemented. The research, based on both documentary analysis and interviews, explores the reasons underpinning the failure of the policy process to respond to such a perceived need. The research findings suggest that the policy formation process in Thailand successfully occurs when there is a critical mass of support from strategic interest groups. The relative power of these interest groups is constantly changing. In particular the last two decades has seen a decline in the power of the bureaucratic élites (military and civilian) and a related rise in the power of the economic élites either directly or through their influence on political parties and government. Other critical groups include the media, NGOs and the professions. Informal policy groups are also significant. A number of implications for policy makers operating under such circumstances are drawn.     

Experiences from the Swedish determinants-based public health policy

A comprehensive Swedish public health policy was adopted by the Swedish Parliament, the Riksdag, in April 2003. It pushes health up on the political agenda and affords equity in health high priority. The first phase of implementation of the policy, 2003-5, is described in the 2005 Public Health Policy Report published by the Swedish National Institute of Public Health (SNIPH). For the purpose of investigating the implementation, SNIPH has monitored the development of 42 determinants and used reports from 22 central agencies and eight county administrative boards together with interviews with all Sweden's county councils (21) and a questionnaire sent out to all municipalities (290). The experiences from the implementation of the policy are that: the determinants approach - focusing on structural factors in society, people's living conditions and health behaviours that affect health - is in general well understood and emphasises the role of other sectors in public health; the use of indicators to follow up exposures to determinants is of key importance; the support to actors outside the health service is needed to identify their public health role; a continuous steering from the government and other political bodies is of vital importance; public health promotion on the regional level needs a higher level of co-ordination; municipalities need more skills development; Sweden has a new government that was elected in September 2006; the new government has retracted the former government's public health policy communication submitted to the Riksdag in the spring of 2006, but does not intend to change the public health policy.     

Health services research and health policy

Health services research (HSR) has the potential to influence the decision-making process in a health services system that is acutely aware of its resource limitations. Nonetheless, health services researchers feel, with some truth, that their research has had only a limited effect on health policy. Some reasons for this are described, including the primacy of political, rather than technical, considerations in policy making, the lack of a comprehensive health policy, and the poor quality and irrelevance of much HSR. The role of funding for HSR by the Federal government is described; it is shown that the Federal effort is fragmented, despite the consolidation efforts made in 1968. Increased support for specific targeted, problem-solving health services research is proposed, and some possible methods to achieve this are described.Dr. Banta is a Professional Staff Member with the Office of Technology Assessment, Congress of the United States, Washington, D.C. 20510, and Associate Clinical Professor, Mount Sinai School of Medicine of the City University of New York. Ms. Bauman is a Professional Staff Member, Committee on Labor and Public Welfare, Senate of the United States, Washington, D.C. 20510. The authors would like to thank Carl Taylor of the Office of Technology Assessment, Arthur Viseltear of Yale University, and Richard Seggel of the Institute of Medicine for their helpful comments. Dr. Banta is grateful to the Robert Wood Johnson Foundation for its support of the Robert Wood Johnson Health Policy Fellowship and to the Institute of Medicine, which developed the Fellowship. A version of this paper was presented at the Medical Care Section, American Public Health Association meetings, Chicago, Illinois, November 19, 1975.     

Balancing health and industrial policy objectives in the pharmaceutical sector: lessons from Australia

INTRODUCTION: Policy-makers worldwide struggle to balance health with industrial policy objectives in the pharmaceutical sector. Tensions arise over pricing and reimbursement in particular. What health plans view as necessary to maintain equitable access to medicines, industry views as inimical to R&D and innovation. Australia has grappled with this issue for years, even incorporating the goal of "maintaining a responsible and viable medicines industry" into its National Medicines Policy. METHODS: This case study was conducted via a narrative review that examined Australia's experiences balancing health and industrial policy objectives in the pharmaceutical sector. The review included electronic databases, grey literature and government publications for reports on relevant Australian policy published over the period 1985-2007. RESULTS: While pharmaceutical companies claim that Australia's pricing and reimbursement policies suppress drug prices and reduce profits, national policy audits indicate these claims are misguided. Australia appears to have secured relatively low prices for generics and "me-too drugs" while paying internationally competitive prices for "breakthrough" medicines. Simultaneously, Australia has focused efforts on local pharmaceutical investment through a variety of industry-targeted R&D incentive policies. DISCUSSION: Despite the fact that policy reviews suggest that Australia has achieved balance between health and industrial policy objectives, the country continues to face criticism from industry that its health goals harm innovation and R&D. Recent reforms raise the question whether Australia can sustain the apparent balance.     

The potential of health sector non-governmental organizations: policy options

Non-governmental organizations (NGOs) have increasingly been promoted as alternative health care providers to the state, furthering the same goals but less hampered by government inefficiencies and resource constraints. However, the reality of NGO health care provision is more complex. Not only is the distinction between government and NGO providers sometimes difficult to determine because of their operational integration, but NGOs may also suffer from resource constraionts and management inefficiencies similar to those of government providers. Some registered NGOs operate as for-profit providers in practice. Policy development must reflect the strengths and weaknesses of NGOs in particular settings and should be built on NGO advantages over government in terms of resource mobilization, efficiency and/or quality. Policy development will always require a strong government presence in co-ordinating and regulating health care provision, and an NGO sector responsive to the policy goals of government.     

The management of health services in Tanzania: a plea for health sector reform

There are essentially four main approaches used in attempts to strengthen the management of health services in developing countries. These are: information system development; management training; use of planning and evaluation methodologies; and, health sector reform. As part of a collaborative research project based in Kisarawe District, Tanzania, we tested the hypothesis that a combination of the first three of these approaches would be sufficient to ensure that decisions and actions were taken to bring about major improvements in the management of health services. It was assumed that the decentralization, which took place as part of the 1982 reorganization of local government responsibilities, had provided managers with sufficient decision-making autonomy to allow them to bring about improvement in health service performance, provided that the other conditions were met. In fact, it was found that despite being presented with clear evidence of serious inefficiencies and inequities in the allocation of health resources, managers were often highly reluctant to decide upon actions which would alleviate the problems in situations where there were potential losers as well as winners, even if the benefits greatly outweighed the costs. This article argues that interventions based solely on training, information systems, or planning and evaluation protocols will make only marginal improvements to health service management, and that changes to the system as a whole are needed in order to provide managers and health professionals with incentives to rectify performance failings. Some ideas for health sector reform, to give managers power and incentives for improving efficiency and quality of care, are put forward. Since it is likely that the systemic problems of the health sector in Tanzania are shared by many other developing countries, the lessons drawn from this study probably have more general applicability.     

Measuring and managing progress in the establishment of basic health services: the Afghanistan health sector balanced scorecard

The Ministry of Public Health (MOPH) of Afghanistan has adopted the Balanced Scorecard (BSC) as a tool to measure and manage performance in delivery of a Basic Package of Health Services. Based on results from the 2004 baseline round, the MOPH identified eight of the 29 indicators on the BSC as priority areas for improvement. Like the 2004 round, the 2005 and 2006 BSCs involved a random selection of more than 600 health facilities, 1700 health workers and 5800 patient-provider interactions. The 2005 and 2006 BSCs demonstrated substantial improvements in all eight of the priority areas compared to 2004 baseline levels, with increases in median provincial scores for presence of active village health councils, availability of essential drugs, functional laboratories, provider knowledge, health worker training, use of clinical guidelines, monitoring of tuberculosis treatment, and provision of delivery care. For three of the priority indicators-drug availability, health worker training and provider knowledge-scores remained unchanged or decreased between 2005 and 2006. This highlights the need to ensure that early gains achieved in establishment of health services in Afghanistan are maintained over time. The use of a coherent and balanced monitoring framework to identify priority areas for improvement and measure performance over time reflects an objectives-based approach to management of health services that is proving to be effective in a difficult environment.